Monthly Archives: June 2006

The post I’m writing about the STATS.org breastfeeding article is getting so long that I’m splitting it into two parts. I’ll look at their use of data and statistical analysis in the second part, but first I wanted to discuss the view of breastfeeding Goldin, Smyth and Foulkes present at the beginning of their article.

They start out by stating that "the costs of nursing are substantial". If they had genuinely been out to present a fair and balanced viewpoint, a statement that the costs of nursing can be substantial for some women would have served that purpose much better. I struggled to nurse a baby with a tongue tie despite a sad lack of local facilities for the simple procedure that would have put things right, and then pumped regularly for eight months after my return to work; I know damn well that breastfeeding can sometimes be difficult. And my experience was a bed of roses compared to that of some women I know. But we’re the exception rather than the rule. For the majority of women, breastfeeding is actually a lot easier overall than formula feeding.

I say "overall" because the first few weeks can be difficult, and breastfeeding at this stage often is more difficult than formula feeding. However, by far the most common experience of women who can hang in there for long enough to get through the initial difficulties is that a few weeks down the line, breastfeeding becomes much easier than formula feeding, to the point where it’s well worth the initial investment of time and energy even from a purely practical point of view. The problems settle down, and you can enjoy not having to spend your time over the rest of the first year mixing formula or sterilising bottles. Of course it doesn’t always happen this way – sometimes the problems don’t settle, and sometimes they’re so severe in the first few weeks that a woman just can’t get past them (although these situations would happen far less frequently if all women had proper advice and support). But a sweeping statement that the costs of nursing are substantial is unwarranted scaremongering.

The article continues: "[T]he reduced time for work due to the need to pump, nurse, eat and sleep has a huge economic and social impact on women and their families." Pumping can certainly be a hassle, though it’s not necessarily as negative as they make out – as I said, I pumped at work for eight months, and neither my employers, my family nor my salary suffered as a result. I just rearranged my schedule to spend the pumping sessions on the paperwork and phone calls that would have had to be done in any case. It was boring and a nuisance, but it was doable. I know that this depends on the job and there are a lot of women for whom pumping at work just isn’t an option – but for a lot of others it’s perfectly feasible, and it’s a possibility of which I’d like to see more women aware. (Mixed feeding is also an option that should be mentioned much more frequently than it is – women who want to breastfeed but can’t/don’t want to pump at work can nearly always still nurse during the times they’re at home.)

But I’m a little confused as to how eating and sleeping ended up on a list of supposed disadvantages of nursing; if I hadn’t breastfed, would I somehow have been magically transformed into a superhuman who could eschew such frailties and work 24/7? I’m also not quite sure why nursing is supposed to take more of women’s time than formula feeding would (surely the reverse is more likely to be true?), unless the authors are trying to suggest that women shouldn’t feed their babies at all but should palm this task off entirely on others while they go and dedicate their time to earning money.

The article continues with a discussion of possible disadvantages of nursing which appears to owe more to a weakness for popular myth than to an attempt to present the facts in a reasonably balanced way. It is indeed possible that an unsuccessful attempt at nursing could worsen depression, but it’s also possible, given the anecdotal evidence of nursing triggering hormonal reactions that lead to relaxed euphoric feelings, that nursing could actually offer some protection against post-partum depression. (In the absence of prospective studies, we can only guess. That applies to STATS.org too.) Nursing can sometimes be painful, but something that is not nearly as widely known as it should be is that pain, far from being an inevitable part of nursing, is nearly always an indicator of a problem that can be straightforwardly solved. There are indeed sometimes medical reasons not to breastfeed, but there are also sometimes medical reasons not to exercise, and for some reason we don’t tend to see that disclaimer showing up in discussions of the overall health benefits of exercise.

CMV infection via breastmilk can affect premature babies, but a quick search through Medline shows that the currently availableevidence doesn’t support this being a major problem, and STATS.org somehow failed to mention that the risk doesn’t seem to affect full-term babies. Drug addicts may well, depending on the drug, be better off not nursing, but I wouldn’t go so far as to call this conclusion obvious – I was told by one of the paediatric consultants I worked for that, apart from cocaine, no drugs are absolute contraindications to breastfeeding, and I know there’s a theory that it may actually help ease withdrawal symptoms in a neonate. Maternal smoking or drinkingmay affect breastfed babies, but don’t seem to do so at low levels. And while some mothers genuinely don’t have enough milk, it’s worth knowing that most of the mothers who think or have been told they don’t have enough actually could have with the proper advice.

Most of what the authors say is not, technically speaking, actually inaccurate. The problem is with the spin they put on it. They seem to be setting out to present breastfeeding in as unmitigatedly negative a way as they can.

Courtesy of Julie, I’ve found that STATS.org are very kindly offering to tell us What Science Really Says About the Benefits of Breast-Feeding. The authors complain that the recent NYT article, while "laying claim to a balanced approach" was, in fact, "extremely biased". The reason this bothers them, as far as I can deduce, is because they don’t see why other people should be the only ones to get all the fun of writing extremely biased articles.

Breastfeeding advocates are as liable as anyone else to fall into the trap of assuming that any evidence that supports their viewpoint must be correct, and I’m all in favour of taking a more thoughtful and analytical approach than "Wahey! Another study showing breastmilk benefits! Take that, anti-breastfeeding formula company dupes!" Unfortunately, while this article raised some good points, it also had several downright inaccuracies and enough spin to make me dizzy. I was left feeling that the authors’ actual goal wasn’t a genuine attempt at weighing the evidence fairly and coming to realistic conclusions about what it does and doesn’t show, so much as a random bashing of breastfeeding, the AAP, and the NYT collectively.

The claims in the article deserve detailed discussion, and I’m working on that. But I’m a slow writer (due, of course, to my dedication to getting every detail meticulously right and well-written into the bargain. Or, if you want to put it another way, to my tiresome anal-retentiveness.) Meanwhile, most people seem to be accepting the STATS.org article with uncritical delight ("See, I knew the NYT had to be exaggerating the benefits of breastfeeding!") and no further questions asked.

In follow-on from the discussion about the NYT article on breastfeeding, Jamie Selkie has been discussing guilt. Why, she asks, is the guilt card a conversation stopper in discussions about breastfeeding and breastfeeding advocacy? Is it possible to avoid making anyone feel guilty about this topic? Should we even be trying to do so?

The short answer to that is: Of course not. You are not going to be able to please all of the people all of the time. The G Word should not be an automatic veto of a subject, because that would leave us unable to talk about anything more contentious than the weather. There is simply no way to discuss hot-button topics, even in the mildest and most unjudgemental of terms, without leaving somebody somewhere feeling guilty. (Jamie’s story about the LLL leader she knows reminded me of my days as a vegetarian – on a number of occasions, I would mention to someone that I was vegetarian and be met with a hasty "Well, I don’t eat meat often! Really! And when I do it’s mostly chicken, and not beef or…". The mere fact that I had decided to avoid meat myself apparently caused some people to mistake me for someone who gave a damn what anybody else did or didn’t decide on this particular issue.)

The problem isn’t with the existence of guilt in this discussion. It’s with the way it’s used. Although a number of breastfeeding advocates don’t seem to make any distinctions here ("What? You mean we can’t nag women about how stupid and dangerous formula-feeding is? Dammit, we’re just not allowed to say anything about breastfeeding these days!"), there’s actually a crucial difference between seeing guilt as an occasional unavoidable evil, and seeing it as a deliberate strategy. Yes, the former should be accepted. But, as I’ve already written, I think there are very good reasons to try to avoid the latter; and we should recognise the difference.

(And this is before we even get onto the subject of a particularly unpleasant habit of some of the more militant wing of breastfeeding advocates – using guilt as revenge. That, I have realised, requires an entire separate post in itself.)

When we raise the subject of breastfeeding, some women, somewhere, are going to feel a pang of guilt about the subject. As good as it would be to be able to avoid that entirely, the cost of doing so would be to deprive other women of the information and support that they need in order to make fully informed choices. We should be willing to raise the subject of breastfeeding with mothers-to-be and new mothers, to check that their reasons for choosing not to breastfeed or to supplement aren’t based on misinformation, to make sure they know where to get more information if they want it. But that doesn’t mean we have to be critical or tactless or bossy or bitchy about doing so.

The question we should be asking ourselves about our attempts at promoting breastfeeding is not "Will this make any women feel guilty?", but "Is this
constructive rather than destructive? Is it, overall, likely to be
helpful?"

Objections that this sort of approach might make formula-feeding mothers feel guilty have been met with much indignation from certain quarters, and although some of this does seem to be due to a "What? You mean I actually have to consider the feelings of a woman so beneath contempt as to feed formula to her baby?" attitude, a lot of it seems to be based more on a belief that breastfeeding is so important that if mothers’ feelings get hurt along the way then that’s a price worth paying.

The problem with this is that it completely misses a crucially important point: People’s feelings play a huge part in determining their actions. The question is not just whether we should be willing to sacrifice women’s feelings on the altar of increased breastfeeding rates, but also whether sacrificing women’s feelings might do breastfeeding rates a lot more harm than good. Ever hear that old saying about how you catch more flies with honey than with vinegar? In general, alienating people isn’t a great way of inspiring them to take your help and advice. It’s a great way of inspiring them to get as far away from you as possible, muttering darkly "What does she know, anyway?"

Think about this. Suppose your knowledge of breastfeeding consists entirely of a general awareness that Breast Is Best and a lot of horror stories from family and friends about how Lots Of Women Don’t Have Enough Milk, Dear, And Besides Cousin Elsie Was In Agony With Her Nipples Until She Switched To A Nice Bottle. Even though you feel you should probably try breastfeeding, the stories you’ve heard about it leave you pretty worried about what the whole business might be like. But, more than that – you’re worried about how you might feel if you try it and it doesn’t work out. Or, worse – suppose you know how you’ll feel if you try it and it doesn’t work out, because it happened to you once before. Suppose you want to try, feel you ought to try – but, at the same time, can’t face the thought of feeling like a failure if you can’t make it work.

Now, suppose that what you see of the pro-breastfeeding camp is an advert designed to put across the message that formula feeding is so dangerous, unnecessary, and generally idiotic that it can be appropriately compared to riding a mechanical bull while heavily pregnant. Or, to put it another way: Hello! We’re here to give you breastfeeding support with a double helping of extra criticism and guilt on the side!

How likely do you think you’d be to call and ask those people for breastfeeding help and advice?

The standard answer to concerns about the guilt issue (and one with which I wholeheartedly agree) is that if a woman really couldn’t breastfeed, she shouldn’t feel guilty. I know that; the lactivists know that. Do the women who need to know that know it? We often make the mistake of talking as though guilt is a logical, rational response. This is even less true in motherhood than in other areas of life, because of the widespread belief that we should all be Supermummy, capable of dealing successfully with any problem or crisis, always getting it right.

Anyone who has worked with people who have been abused in any way knows that, ironically, guilt is a common reaction on the part of the person abused. Emily (whose story I used to have a link to, but, unfortunately, her site has been abandoned and then hacked and so I’ve had to delete all links to it) is an example of this. I’m not talking about the abuse she received as a child, although I’m aware it’s relevant to her reaction; I’m talking about the abuse she received at the hands of the medical professionals who were meant to help her breastfeed and screwed up dismally. Emily was left feeling as though she, rather than they, was the failure. Is that logical? No. Did the lack of logic stop her feeling that way? No. Is it constructive or helpful for her to have people giving her the message that not only is it All Her Fault that she didn’t breastfeed, but that if that message makes her feel guilty then that’s her problem for reacting to it the wrong way? I’m guessing probably not.

Oh, it’s entirely possible the advert works on some people. Guilt can sometimes be a powerful motivator – I’m sure we can all think of times when it’s spurred us into tidying that cupboard, getting that presentation done, going for that workout at the gym. Thing is – how many times have you pulled the door firmly shut on that messy cupboard or sat eating chocolate to drown your guilt over not exercising? How many times has guilt had the reverse effect, pricking you into trying to get your thoughts as far away as possible from whatever it is you’re trying to avoid doing?

Do we have any idea how many people were put off by this advert rather than inspired by it? Do we really want to risk the possibility that this approach does more harm than good?

But this advertising campaign bothers me not just because of the possible harms, but also because of the missed opportunity. The information it gave wasn’t the information that is actually needed most.

I really don’t think there are substantial numbers of people out there who are genuinely oblivious to the fact that there are certain claimed advantages for breast milk. There are certainly people who choose, for whatever reason, to ignore the fact; but something tells me that showing them a picture of a pregnant woman on a mechanical bull isn’t going to make them slap their foreheads and cry "Mechanical bull? Dammit, those breastfeeding advocates were right all along!" (I’m concerned it might be more likely to have the opposite effect; "Mechanical bull? These idiots are trying to claim that formula is as risky as taking a fetus on a mechanical bull? Well, who wants to listen to anything they have to say?!") The biggest area of ignorance in breastfeeding isn’t about whether or not it’s better, but about how to do it.

Just imagine that the advertising campaigners had used their brief slot on screen to try to put across that sort of information. Oh, of course you can’t use that kind of timespan to make the public into breastfeeding experts – but I don’t think you need to. I think that it could have been responsibly used to make people aware that problems can usually be overcome and that many of the supposed indications for stopping breastfeeding are actually nothing of the sort.

So, for example, the voiceover could have said something like "I didn’t think I could make breastfeeding work at first – my nipples were sore and I felt exhausted. But when I contacted <whatever the organisation’s called> they were really helpful, and now everything’s going wonderfully – I’m so glad I persevered." There are a lot of possible alternatives I can think of – the "My doctor told me I didn’t have enough milk" story, the "I thought I wouldn’t be able to combine breastfeeding and work" story (with the variations of either pumping at work or breastfeeding morning and night while formula-feeding at other times), the "Other people told me I could never do it…" story.

And for the camera work? Scenes of a woman working breastfeeding into her normal life. Sitting comfortably at home feeding a baby, doing something one-handed while nursing the baby with the other, nursing in public. Just pleasant ordinary scenes of how breastfeeding can be happily and naturally integrated into life in general – a subtle positive message to the subconscious, to counteract the bottle-as-norm images that we seem to see everywhere else.

If we ever have a national television advertising campaign encouraging breastfeeding in this country, then that’s the kind of thing I’d like it to show. But it still strikes me as a lot less important than other things that need to be done. For example, while we already have the excellent maternity leaves that US mothers yearn for, what we don’t have is legal support for the right to breastfeed in public. I’d like to see that put in place. And I’d really like to see proper, evidence-based breastfeeding education made a mandatory part of the education of doctors, midwives and health visitors.

Those are the things I hoped for when I signed the petition. I really hope that those, rather than yet another round of Do Things This Way Or Forever Wear The Bad Mother Label Of Shame, are the things we get.

Ladies and gentlemen, I give you Science Myth 5: The ‘Natural’ myth. This is the belief that the safety and desirability of an activity/way of doing things is best judged by the degree of technology involved. The reason I’ve phrased this in such a cumbersome way is because the myth covers two mirror-image philosophies:

Myth 5a – If it’s natural, it’s bound to be safe. For example: childbirth is natural, and women’s bodies have evolved/been designed to give birth safely. Less hi-tech medical intervention is obviously better!

Myth 5b – If it’s high-tech, it’s bound to be safe. Childbirth is horribly dangerous, and is bound to be safer if you’re in hospital with all available monitors, drugs, machines that go ‘ping’, and the like. More hi-tech medical intervention is obviously better!

Truth – While there would have been obvious problems for the survival of the human race if women couldn’t give birth successfully without intervention in most cases, the key word there is ‘most’. Evolution is sloppy. It allows for a fair bit of wastage as long as things work well enough for the race to survive overall, and does not care about the fact that that ‘wastage’ is somebody’s dead baby or mother. And, although I’m using childbirth as the example here because that’s the one that happened to come up, this applies just as much to the many, many other situations in which ‘natural’ is automatically considered to be synonymous with ‘optimal’. There is no logical reason to assume that we may not, in at least some cases, be able to design a way of doing things that works better than the ‘natural’ way.

However, people who rightly spot the fallacy with this side of the ‘natural’ myth are astonishingly good at missing the other side – it is equally fallacious to assume that just because a way of doing things involves more action and more exciting-looking machines going ‘ping’, then it must automatically be better.

Truth 5a and 5b – There are situations where technology helps, situations where it doesn’t help, and situations where it harms, and there is no logical basis for making any assumptions, one way or the other, as to whether more ‘hi-tech’ ways of things are going to be better or worse than more ‘natural’ ways. The correct way to go about things is to try to collect as much evidence as possible and to be realistic about the inevitable limitations of said evidence, while at the same time being willing to look at what the evidence actually says rather than at what we’ve already assumed it should say. Thus, the appropriate pro-homebirth argument would not be "A woman’s body was designed to give birth safely!" but "Several studies comparing homebirth with hospital birth have shown homebirth to be of comparable safety to hospital birth in low-risk women", and the appropriate anti-homebirth argument would not be "How could a woman be so selfish as to do something so stupid and dangerous?!" but "Although I realise the research supposedly seems to show the safety of homebirth, I disagree with the findings because…"

The interesting thing is that, while the homebirth debate seems to have its fair share of followers of Science Myth 5 represented on both sides of the debate, the more evidence-based style of argument seems to be found exclusively on the pro-homebirth side. I’m sure this can’t be literally true: I’m sure there must be anti-homebirthers whose contributions to the subject consist of thoughtful analytical commentaries on the ways in which they feel the studies showing the safety of homebirth to be flawed, who discuss the evidence instead of ignoring it, who don’t resort to berating or belittling or mocking pro-homebirthers. But, unfortunately, I just never seem to run across them.

I’m so sorry. I’ve been neglecting this blog shamefully, haven’t I? I must say, I was terribly touched to drop in here and discover a comment from a delurker begging me to come back (Hi, PhoebeR!). Always nice to know you’ve been missed.

I have no terribly good excuses for my absence, I’m afraid – just been doing stuff on various newsgroups and other corners of the Internet, and the half-dozen or so potential blog posts swimming around in the murky corners of my brain have just never been actualised. But, yes, I’m still around, and will try to do something to prove it in the not-too-horrendously-distant future.